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Brachial plexus birth palsy

  • We push innovation in our department by sub-specializing--gaining ever more expertise with complex problems, and developing ever newer methods.

    --Peter Waters, MD, clinical chief, Orthopedic Center; director, Brachial Plexus Program, Boston Children's Hospital

    If your baby or child has been diagnosed with brachial plexus birth palsy (BPBP), we know that you and your family are worried about her future, and maybe even under some stress. So, please know that at Boston Children's Hospital, we will approach your child’s treatment and care with sensitivity and support—for your child and your whole family.

    If your child has BPBP, it means that during childbirth she had an injury to the brachial plexus (BP) network of nerves that travel from her neck, through the shoulder region down to the arm and hand. The BP nerve network provides the electrical power to all the muscles of her arm.

    • BPBP occurs in about one to three out of every 1,000 babies born.
    • The condition’s severity and type depend on:
      • where in the nerve injury occurs
      • whether the injury is a stretch, an incomplete tear or a complete tear (avulsion)
    • In over half of cases, the injury heals itself within the first month to six weeks.
    • Nerve surgery may be recommended if marked weakness persists after three to six months.
    • Some children benefit from muscle, tendon, bone and joint surgery between years age 2-5 years.
    • BPBP is a serious but treatable condition.

     

    How Boston Children's Hospital approaches brachial plexus birth palsy

    You can have peace of mind knowing that the team in Children’s Brachial Plexus Program has treated hundreds to thousands of babies and children—as well as adolescents, young adults and even professional athletes who’ve sustained traumatic BP injury.

    Some of the world’s most advanced clinical research into BP anatomy and treatment is coming from Boston Children’s researchers. So, we can provide your child with expert diagnosis, treatment and care—as well as the benefits of some of the best BPBP clinical and scientific research in the world.

    As one of the first comprehensive, multidisciplinary programs, Boston Children’s Orthopedic Center is the nation’s largest and most experienced pediatric orthopedic surgery center, performing more than 6,000 surgical procedures each year. Our program—ranked among the top in the nation by U.S. News & World Report—is the preeminent care and research center for children and young adults with congenital, neuromuscular, developmental and post-traumatic musculoskeletal problems.

    As a national and international referral center for children with brachial plexus birth palsy, the Brachial Plexus Program within the Orthopedic Care Center is among the largest in the world—caring for more than 1200 children with brachial plexus birth palsy since its inception.

    Using a research- and innovation-driven approach, our program’s team of surgeons, nurses and therapists provides services that include:

    Brachial plexus birth palsy: Reviewed by Peter Waters, MD
    © Boston Children’s Hospital, 2011

    A long line of orthopedic firsts

     With a long history of excellence and innovation and a team of clinicians and researchers at the forefront of orthopedic research and care, Boston Children’s is home to many treatment breakthroughs:

    • advanced techniques and microsurgery care for complex fractures and soft tissue injuries to the hand and upper extremity
    • advances in our spinal program, such as video-assisted thorascopic surgery
    • the oldest and largest comprehensive center for the care of spina bifida
    • a hip program that has performed over 1,400 periacetabular osteotomies
    • one of the first scoliosis clinics in the nation
    • one of the first sports medicine clinics in the nation
    • one of the first centers in the nation to use adjuvant chemotherapy and perform limb salvage surgery for patients with osteosarcoma

    Brachial Plexus Program

    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
    617-355-6021

    Boston Children's Hospital at Waltham
    9 Hope Avenue
    Waltham MA 02453
    617-355-6021

    Boston Children's North
    10 Centennial Drive
    Peabody MA 01960
    617-355-6021

  • At Boston Children's Hospital, our Brachial Plexus Program team knows how concerned you are that your baby sustained an injury to her brachial plexus nerve network. We’ve developed innovative non-surgical and surgical treatments for children with all degrees of severity of brachial plexus birth palsy (BPBP). Learning more about this injury will help you feel more confident and in control as we treat—and work toward—healing your child.
     

    What is the brachial plexus?

    The brachial plexus is a complex network of nerves between the neck and shoulders. These nerves control muscle function in the chest, shoulder, arms and hands, as well as sensibility (feeling) in the upper limbs.

    What is brachial plexus birth palsy (BPBP)?

    Brachial plexus birth palsy is an injury to the brachial plexus nerves that occurs during childbirth. The nerves of the brachial plexus may be stretched, compressed, or torn in a difficult delivery. The result might be a loss of muscle function, or even paralysis of the upper arm. Injuries may affect all or only a part of the brachial plexus:

    • Injuries to the upper brachial plexus (C5, C6) affect muscles of the shoulder and elbow.
    • Injuries to the lower brachial plexus (C7, C8 and T1) can affect muscles of the forearm and hand.

    What happens during childbirth to cause an injury to the brachial plexus?

    During childbirth, stress can occur across a baby’s neck and head area, injuring the nerve(s). This stress usually happens when the head goes in one direction and the shoulder goes in another direction.

    Can injury to the brachial plexus nerve network happen in other circumstances than childbirth?

    Yes, a traumatic brachial plexus injury can occur at any age—often as a result of a sports injury or car or work accident.
     

    What are the types of brachial plexus birth palsy?

    Brachial plexus birth palsies are often categorized according to the type of nerve injury and the pattern of nerves involved.

    • four types of nerve injuries

      • stretch (neurapraxia)
        • The nerve has been stretched but not torn—the injury occurs outside the spinal cord.
        • It’s the most common form.
        • Affected nerve(s) may recover on their own—usually within 3 months of the baby’s life.
      • rupture
        • The nerve is torn, but not where it attaches to the spine—the injury occurs outside the spinal cord.
        • It’s a common form.
        • It may require surgical repair.
      • avulsion
        • The nerve roots are torn from the spinal cord—the injury occurs at the spinal cord.
        • This is a less common form (roughly 10 to 20 percent of BP cases)
        • It cannot be surgically repaired directly—damaged tissue must be surgically replaced (nerve transfers).
        • It can injure the nerve to the diaphragm, causing difficulty with breathing.
        • A droopy eyelid on the affected side may indicate a more severe injury (Horner’s syndrome).
      • neuroma
        • The nerve has tried to heal, but scar tissue has formed and presses against the injured nerve or interferes with nerve function.
        • It may require surgical treatment with nerve reconstruction and/or secondary tendon transfers.
    • patterns of nerve injury

      • C5-C6-C7 (formerly called Erb’s palsy)
        • This represents roughly 60 to 70 percent of BPBP injuries.
        • It involves the upper portion (C5, C6, and sometimes C7) of the brachial plexus.
        • A child typically has weakness involving the muscles of the shoulder and biceps.
        • Home physical therapy begins when a baby is 3 weeks old to prevent stiffness, atrophy and shoulder dislocation.
      • C5-T1 (total plexus involvement)
        • This represents roughly 20 to 30 percent of BPBP injuries.
      • Horner’s syndrome
        • This represents roughly 10 to 20 percent of injuries.
        • It is usually associated with an avulsion (a tear at the spinal cord).
        • The sympathetic chain of nerves has been injured, usually in the T2 to T4 region.
        • The child may have ptosis (drooping eyelid), miosis (smaller pupil of the eye), and anhydrosis (diminished sweat production in part of the face).
        • The child may have a more severe injury of the brachial plexus.
      • Klumpke’s palsy
        • This almost never occurs in babies or children
        • It involves the lower roots (C8, T1) of the brachial plexus.
        • It typically affects the muscles of the hand.

    How common is brachial plexus birth palsy?

    Brachial plexus birth palsies occur in about one to three out of every 1,000 births.

    What are the risk factors for BPBP?

    Risk factors for sustaining brachial plexus birth palsy include:

    • large gestational size
    • breech birth
    • prolonged or difficult labor
    • vacuum- or forceps-assisted delivery
    • twin or multiple pregnancy
    • history of a prior delivery resulting in brachial plexus birth palsy

    Does BPBP cause the baby pain?

    Usually, the baby is not in much pain despite her BPBP, probably because infants’ nerves behave differently from adults’. Roughly, just 4 percent seem to experience severe pain. If a fracture accompanies the BPBP, the baby will experience some discomfort from the fracture, but not usually intense pain. And any fractures (clavicle, humerus) the baby may have will probably heal quickly—in about 10 days.

    This is in contrast to an adult’s traumatic brachial plexus injury caused by accident or sports impact: In these cases, pain from BP injury is acute and disabling, as is pain from any accompanying fractures.

    What's the prognosis if my child has brachial plexus birth palsy?

    The prognosis is dependent on the extent of the injury, and for this reason, it varies from patient to patient:

    • Most children achieve normal or near-normal arm function without surgery. But not all children recover fully.
    • If a child does not recover fully, surgery can improve her strength and/or motion and help optimize shoulder joint development.
    • One of the common problems with brachial plexus birth palsies can be the abnormal development of the child’s shoulder joint, which can happen over time. So, in addition to physical examinations, your child may need ultrasound, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans to monitor her shoulder development.
       

    Will my child be OK?

    The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re 6 weeks old. Less than half of children with BPBP need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

    If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

    Children’s pioneering research into the biology of brachial plexus birth palsy—and our experience in developing innovative treatments—means that your child will receive the most advanced care possible.

    What's unique about BPBP care at Children's?

    Boston Children’s Brachial Plexus Program is one of the world’s major centers for BPBP treatment. The program stands virtually alone in providing the entire spectrum of BPBP care—from early nerve surgery, to early therapy, to later reconstructive orthopedic surgery and therapy if this is needed. Our experts sub-specialize in BPBP, and we provide the entire spectrum of care all within one program. So, our team can follow your child closely throughout her treatment and recovery. 

    Causes/risks

    • large gestational size
    • breech birth
    • prolonged or difficult labor
    • vacuum- or forceps-assisted delivery
    • twin or multiple pregnancy
    • history of a prior delivery resulting in brachial plexus birth palsy

    Signs and symptoms

    The main sign of brachial plexus birth palsy is that one of the newborn’s arms will lie at her side, sometimes in a “waiter’s tip” posture. The affected arm/hand does not move normally, in contrast to her other side.

    When to see a specialist

    Once your child’s pediatrician has made a diagnosis, it’s safe to wait up to four weeks for a comprehensive evaluation by an orthopedist and/or brachial plexus specialist.

    Complications

    Complications after surgery are uncommon but can occur, and can be either temporary or permanent. These include:

    • stiff joints—can be treated with physical therapy
    • pain from nerve damage (very unlikely)
    • muscle atrophy due to incomplete recovery
    • disability from incomplete recovery
    • the biggest worry is that the arm and hand will not get as close to normal as hoped

    Generally, surgery does not make children worse, but does not always lead to full recovery.

    Long-term outlook

    The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re just 6 weeks old. Less than half of children with BPBP will need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

    If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

    For parents

    Many parents whose babies are diagnosed with BPBP feel disappointed and frustrated that the birth of their child didn’t turn out the way they’d dreamed it would. Your child’s treatment and recovery may be fairly easy. Or, the journey may be more complicated—requiring surgery for your child, and several years of your dedication to her home therapy.

    Even though you understand the importance of surgery and therapy for your child with BPBP, you still might experience her treatment and recovery as a difficult time and process. If you feel frustrated or depressed, speak to your doctor or counselor to get help. Professionals in the Brachial Plexus Program and The Center for Families can provide you with important resources and referrals.

  • At Boston Children's Hospital, we understand that the first step to treating your child is obtaining an accurate, timely and thorough diagnosis.

    How is brachial plexus birth palsy diagnosed?

    Brachial plexus birth palsy can be diagnosed by your baby’s pediatrician upon a thorough medical history and physical examination. Since the majority of babies with a brachial plexus injury recover in the first month to six weeks after they’re born, these exams can be scheduled with a primary care doctor. Children who continue to have problems beyond six weeks should be seen by an orthopedist or brachial plexus specialist.

    In addition to a physical exam, doctors may conduct special imaging studies like an MRI or nerve conduction studies, although for babies, these tests are not as reliable as they are for adults and require anesthesia. If doctors suspect that your child also has a fracture, they may take an x-ray, too. It’s important to find an experienced doctor who will be able to track your child’s progress over repeated exams.

  • Boston Children's Hospital's Brachial Plexus Program provides comprehensive care—including evaluation, diagnosis, consultation, surgery, non-surgical therapies and follow-up care, which may include:

    • observation:
      • Most brachial plexus birth palsies will heal on their own. Your doctor will monitor your child closely.
      • Many children improve or recover by 3 to 12 months of age. During this time, ongoing exams should be performed to monitor progress.
    • physical therapy (and/or occupational therapy):
      • Therapy is recommended to help maximize use of the affected arm and prevent tightening of the muscles and joints.
      • With the teaching and guidance of therapists, parents learn how to perform range of motion (ROM) exercises at home with their child several times a day. These exercises are important to keep the joints and muscles moving as normally as possible.
    • Botox injections: may be used (mainly for the shoulder) to:
      • help with joint motion
      • rebalance muscles
      • prevent contractures and shoulder dislocations
    • surgery: Children who continue to have problems three to six months after birth may benefit from surgical treatment
       

    Your child's doctors have several surgical options for treating brachial plexus birth palsy, including:

    •  microsurgery (10 to 20 percent of all BPBP surgery)
      • recommended if recovery is still inadequate three to six months after birth
      • to repair or reconstruct the injured nerves
      • can be “nerve grafts,” usually from the leg (sural nerves) between nerve root and nerve to muscle
      • can be “nerve transfers” from other areas of the brachial plexus (or other areas of the body): for more serious BPBP (avulsion)
      • nerve reconstruction is best performed between 3 and 9 months of life and is usually not beneficial for children beyond 1 year of age
         
    • tendon transfers
      • involves separating the tendon from its normal attachment and reattaching it to a new location
      • allows a healthy muscle to help a weaker or injured muscle perform its desired function
      • usually performed around the shoulder to improve the ability to raise the arm, but may be used in forearm, wrist or hand
      • done between 1 year of age and adulthood
      • patients usually in a cast for four to six weeks after surgery
      • extensive post-operative therapy
      • in some cases, shoulder weakness may cause limitations in motion that aren't amenable to tendon transfers
         
    • open reduction of the shoulder joint (capsulorraphy)
      • reducing (placing the humeral head back in joint) and surgically tightening loose tissue around the shoulder joint
      • usually performed when persistent muscle weakness has caused shoulder joint instability or dislocation
      • performed:
        • through a surgical incision (“open”) -or-
        • using arthroscopy
          • pencil-sized camera is inserted into the shoulder via smaller incisions
      • often performed in conjunction with other surgical procedures
         
    • osteotomy
      • procedure in which bones are cut and reoriented
      • may improve upper extremity function by better positioning the hand and arm
      • most commonly performed on the humerus (upper arm bone) or forearm
         
    • free muscle transfers
      • typically using muscle (gracilis) from patient's leg(s)
      • extensive surgery requiring reconnection of blood vessels and nerves under microscope
      • used only when there are no local muscles in the arm or hand to replace dysfunctional muscles

    Complications after surgery

    Complications after surgery are uncommon but can occur, and can be either temporary or permanent. These include:

    • stiff joints—can be treated with physical therapy
    • pain from nerve damage (very unlikely)
    • muscle atrophy due to incomplete recovery
    • disability from incomplete recovery
    • the biggest worry is that the arm and hand will not get as close to normal as hoped

    Generally, surgery does not make children worse, but does not always lead to full recovery.

    Caring for your child after surgery

    After your child's BPBP surgery, her Boston Children's pediatric orthopedist and physical therapist will advise you of physical therapy exercises you can do with your child at home. Her doctor can also help you plan a nutritional program and a personal exercise regimen to optimize your child's recovery.

    Long-term outlook

    The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they're 6 to 12 months old. Some may even begin to recover when they're just 6 weeks old. Less than half of children with BPBP will need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

    If needed, your child's rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

    Coping and support

    At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit The Center for Families for all you need to know about:

    • getting toBoston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with BPBP. Will this affect my child long term? When can she return to her sports and activities? Children's can connect you with extensive resources to help you and your family through this stressful time, including:

    • patient education: From doctor's appointments to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child's treatment and help answer any questions you may have—Why will my child need surgery? Are there non-surgical options? How long will her recovery take? How should we manage home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Boston Children's.
       
    • parent-to-parent: Want to talk with someone whose child has been treated for BPBP? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share their experiences.
       
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Boston Children's chaplaincy. Our program includes nearly a dozen clergy— representing Protestant, Jewish, Muslim, Roman Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
       
    • social work: Our social workers and mental health clinicians have helped many families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.
  • Research & Innovation

    For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research—pioneering treatment approaches and major advances in the care and treatment of trauma to the joint, scoliosis, polio, TB, hip dysplasias and traumas to the hand and upper extremities.

    Our research helps answer the most pressing questions in pediatric orthopedics today—providing the children we treat with the most innovative care available.
     

    Clinical studies for brachial plexus birth palsy

    The natural history of brachial plexus birth palsy remains unknown, in part due to a lack of information on patients evaluated from birth to adulthood. Based on what’s currently known about BPBP, it’s generally accepted that microsurgery benefits infants:

    • without recovery of biceps function by the age of 6 months, and
    • with severe avulsion (a tear of the nerve at the spinal cord) injuries by 3 to 6 months of age

    However, there’s significant controversy regarding the ideal timing for microsurgery whose long-term outcomes are unknown. The Brachial Plexus Program’s long-term TOBI (Treatment and Outcomes of Brachial Plexus Injury) study of BPBP treatment is an international effort that includes centers from North America, Europe and Australia.

    Within Boston Children’s Orthopedic Center, the Brachial Plexus Program and the Clinical Effectiveness Research Center (CERC) are doing extensive research on brachial plexus birth palsy, including grant-funded research through the American Society for Surgery of the Hand (ASSH) and the Pediatric Orthopaedic Society of North America (POSNA). This includes coordinating and analyzing data on brachial plexus patients from centers throughout North America in the TOBI (Treatment and Outcomes Brachial Plexus Injuries) study.

    The primary goal of this multi-center study is to determine the optimal age for microsurgical repair in infants with brachial plexus birth palsy and persistent upper extremity weakness. We’ll also compare the results of early microsurgery to those of secondary reconstructive surgery.

    This research is an effort to establish a standard of care at all hospitals, and to determine the natural history (spontaneous recovery) and microsurgery results for brachial plexus injuries. Our program is coordinating this multi-center TOBI study over the next five years to determine the timing of microsurgery, tendon transfers and osteotomies.

    We present all of our research papers on a national basis and publish these results in peer review journals. Numerous papers have already been published and presented in these areas and will continue to be published prospectively.

    Please note: All patients with BPBP are invited to participate in this clinical study. During your visit with us, you will be approached by a research coordinator to participate in this and other studies—to help your child, you, and other children and parents determine what is best for infants and children with brachial plexus injuries.

    Our Orthopedic Clinical Effectiveness Research Center (CERC)

    The Clinical Effectiveness Research Center (CERC) was established by the Orthopedic Center to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and is playing an instrumental role in establishing, for the first time, evidence-based standards of care for pediatric orthopedic patients throughout the world. 

  • Johanna’s story: brachial plexus can’t keep her down

    Johanna Krayeski recovers after surgeryLike most new parents, we eagerly waited for nine months to meet our little troublemaker, wondering if she would have blue eyes like daddy or green ones like mommy, if she would have hair or be bald, what it would feel like to hold her in our arms. The words that came out of our doctor’s mouth a few hours after our daughter was born were the last ones we expected: “brachial plexus injury.”

    Read more.

    Gift of grab: Brachial plexus surgery helps tot hug and hold for the first time

    “When I first met Dr. Waters, I felt like he was an angel. I knew we were in the right place and in the right hands,” recalls Jonathan Mora. It was November 2009, and the West Haven, Conn. father, his wife and their 6-month-old daughter Michelle had endured a bumpy ride since her birth on May 30, 2009.

    Read more.

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